Office for Civil Rights Requires Posted Nondiscrimination Policies and Grievance Procedures for Patients

Written by: Christopher J. Pyles, Esq.

Every medical care provider is familiar with the obligation to post notices to employees that explain nondiscrimination policies and other protections. However, medical care providers receiving federal funds have additional posting obligations to patients.

Recipients of federal financial assistance from the U.S. Department of Health & Human Services must have a Nondiscrimination Policy relating to admission and treatment, and disseminate that Policy in an acceptable fashion. A general notice of equal employment opportunities will probably not suffice because it is limited to employees, whereas the broader Office for Civil Rights (OCR) requirement applies to clients, beneficiaries and/or patients. For further details, please refer to the following link: http://www.hhs.gov/ocr/civilrights/clearance/tanonfiscriminationpoliciesandnotices.html.

The policy examples from OCR state that the nondiscrimination policy must be posted, and/or added to advertising or admissions packages. Those posted examples are as follow:

Example of a Nondiscrimination Policy

Example One (for posting in the facility and inserting in advertising or admissions packages):

NONDISCRIMINATION POLICY

As a recipient of Federal financial assistance, (insert name of provider) does not exclude, deny benefits to, or otherwise discriminate against any person on the basis of race, color, national origin, disability, or age in admission to, participation in, or receipt of the services and benefits under any of its programs and activities, whether carried out by (insert name of provider) directly or through a contractor or any other entity with which (insert name of provider) arranges to carry out its programs and activities.

This statement is in accordance with the provisions of Title VI of the Civil Rights Act of 1964, Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Regulations of the U.S. Department of Health and Human Services issued pursuant to these statutes at Title 45 Code of Federal Regulations Parts 80, 84, and 91.

In case of questions, please contact:

Provider Name:

Contact Person/Section 504 Coordinator:

Telephone number:

TDD or State Relay number:

Example Two (for use in brochures, pamphlets, publications, etc.):

(Insert name of provider) does not discriminate against any person on the basis of race, color, national origin, disability, or age in admission, treatment, or participation in its programs, services and activities, or in employment. For further information about this policy, contact: (insert name of Section 504 Coordinator, phone number, TDD/State Relay).

Please also note that 45 CFR §84.7(b) requires any facility with 15 or more employees to have grievance procedures with appropriate due process standards. Grievance procedures that are limited to employees or generally referenced in a “Patient’s Bill of Rights” are not typically acceptable. Therefore, the procedure must be available for clients, beneficiaries and/or patients and posted in a conspicuous location or locations within the facility. The OCR website provides guidance here: http://www.hhs.gov/ocr/civilrights/clearance/tarequirementforfacilitieswith15ormoreempl.html.

Additionally, OCR has provided a specific format that may be used as follows:

SECTION 504 GRIEVANCE PROCEDURE

It is the policy of (insert name of facility/agency) not to discriminate on the basis of disability. (Insert name of facility/agency) has adopted an internal grievance procedure providing for prompt and equitable resolution of complaints alleging any action prohibited by Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794) of the U.S. Department of Health and Human Services regulations implementing the Act.  Section 504 prohibits discrimination on the basis of disability in any program or activity receiving Federal financial assistance. The Law and Regulations may be examined in the office of (insert name, title, tel. no. of Section 504 Coordinator), who has been designated to coordinate the efforts of (insert name of facility/agency) to comply with Section 504.

Any person who believes she or he has been subjected to discrimination on the basis of disability may file a grievance under this procedure. It is against the law for (insert name of facility/agency) to retaliate against anyone who files a grievance or cooperates in the investigation of a grievance.

Procedure:

  • Grievances must be submitted to the Section 504 Coordinator within (insert timeframe) of the date the person filing the grievance becomes aware of the alleged discriminatory action.
  • A complaint must be in writing, containing the name and address of the person filing it. The complaint must state the problem or action alleged to be discriminatory and the remedy or relief sought.
  • The Section 504 Coordinator (or her/his designee) shall conduct an investigation of the complaint. This investigation may be informal, but it must be thorough, affording all interested persons an opportunity to submit evidence relevant to the complaint. The Section 504 Coordinator will maintain the files and records of (insert name of facility/agency) relating to such grievances.
  • The Section 504 Coordinator will issue a written decision on the grievance no later than 30 days after its filing.
  • The person filing the grievance may appeal the decision of the Section 504 Coordinator by writing to the (Administrator/Chief Executive Officer/Board of Directors/etc.) within 15 days of receiving the Section 504 Coordinator’s decision. The (Administrator/Chief Executive Officer/Board ofDirectors/etc.) shall issue a written decision in response to the appeal no later than 30 days after its filing.
  • The availability and use of this grievance procedure does not prevent a person from filing a complaint of discrimination on the basis of disability with the U. S. Department of Health and Human Services, Office for Civil Rights.

(Insert name of facility/agency) will make appropriate arrangements to ensure that disabled persons are provided other accommodations, if needed, to participate in this grievance process. Such arrangements may include, but are not limited to, providing interpreters for the deaf, providing taped cassettes of material for the blind, or assuring a barrier-free location for the proceedings. The Section 504 Coordinator will be responsible for such arrangements.

Your facility probably has these policies and procedures in place already, but it is prudent to periodically check and make sure the appropriate standards are in place. If you have any questions, please call me at (603) 223-2834, send me an e-mail at cpyles@sulloway.com, or contact the Sulloway & Hollis Health Care Practice Group headed by Doug Chamberlain and Rob Lanney.